A Day in the Life Of a Baghdad ER

By Bobby Ghosh

It is morning rush hour in Baghdad, and the emergency-room staff at Yarmouk Hospital is bracing itself for another grim load. Insurgent groups routinely mount their biggest attacks during the commuter crush: the heavy traffic guarantees them a high death toll, and the ensuing snarl-ups prevent police and military units from giving chase. For medical workers like Dr. Jalal Taha Emad, an emergency-room surgeon, each day begins with a foreboding of the mayhem to come. "When I am on my way to work, I sometimes look at people in the cars around me and wonder how many of them will end up on the beds of my hospital. I suppose one day I could be lying on one of them," he says, casting a glance at the ER's 12 iron-frame beds, covered in green plastic sheets that bear the bloodstains of countless patients who have gone before. "But I try not to think about that."

For Iraqis, denial can be the best way to cope with the knowledge that a sudden, violent death is merely a matter of being on the wrong street corner at the wrong time. For the 138,000 U.S. troops serving in Iraq, there are few refuges from the arbitrary violence that continues to plague much of the country; for Iraqi civilians there are none. After a two-month lull following the Jan. 30 election, attacks by insurgent groups have spiked over the past two weeks, coinciding with the formation of a new government. Most of the recent wave of attacks, which have already killed nearly 300 people since early May, are targeted at Iraqi police and security services. But as always, ordinary, defenseless civilians are caught in the middle. In Baghdad just driving to work is a deadly daily game of Russian roulette.

Many of the victims end up in the ER at Yarmouk Hospital, a beige concrete-and-brick building that looks more like an old warehouse than one of the country's best-regarded medical facilities. The Yarmouk district, on Baghdad's western flank, is ringed by the city's most violent neighborhoods, where insurgents tend to concentrate their attacks. Chief surgeon Jamil Bayati estimates that his tiny ER has taken in 10,000 people in the past 12 months and that more than 1,000 of them had "war wounds"--inflicted by insurgents, the U.S. military or Iraqi security forces. Bayati figures that "this is the busiest ER in the world."

To chronicle the devastating toll of the war on the daily lives of Iraqis, I spent part of last week in Bayati's ER. In the midst of my reporting, the story turned highly personal: two members of TIME's Baghdad staff became victims of a bomb blast and were rushed to Yarmouk Hospital. From that point on, I was intimately involved in nearly every decision the doctors and staff made as they struggled to keep my badly wounded colleagues alive. In the process, I experienced the anger, anxiety, frustration and sorrow that so many Iraqis must endure, often in far greater measure, on a daily basis. For every story like ours--which turned out better than we could ever have hoped--there are dozens of others at the ER that end in quiet tragedy.

The day had begun routinely. Salahdin (Captain Salah) Mahmoud, 47, an interpreter for TIME, and bureau assistant Talal Abu Karam, 50, were driving to an assignment when they found themselves sandwiched between two U.S. military patrols at a busy intersection in the western district of al-Qadisiyah. Both men knew immediately that their risky commute had suddenly become a lot riskier. Military patrols are frequently attacked by insurgent groups, and passing civilian vehicles often end up as collateral damage. As Abu Karam stopped to let the second patrol pass, Salah said, "This is not good."

Moments later, a huge blast ripped into the powder blue 1981 Toyota Corona, hurling it across the three-lane road. An improvised explosive device, intended for the patrols, had gone off just 10 feet from the car. The two men were slammed against the windshield, shattering it, and were showered by a hail of shrapnel. Salah's left arm and hand were torn to shreds below the elbow, and blood spurted from two gaping wounds in his left thigh. Both men were lacerated by shrapnel and burned. A shard of glass cut a deep gash in Abu Karam's neck. The blast also damaged a second car, with shrapnel hitting its driver, university student Leith Waleed, in the back of his head.

Some 200 yards behind them, taxi driver Emad Hasan watched as Salah and Abu Karam dragged themselves out of the burning wreckage and collapsed on the road, their clothes in tatters and both bleeding profusely from multiple wounds. As they lay moaning, a crowd of commuters gathered--but kept their distance. "Nobody dared to go near them for 10 minutes," says Hasan, "because we were all afraid there might be a second blast."

The explosion could be heard two miles away in the Yarmouk Hospital. Dr. Jalal Taha Emad told his crew to prepare to receive the wounded. "I heard the explosion in the distance," he says, "and I guessed that the ER was going to get very busy."

Prepping the ER is a simple business; there is not much to get ready. Apart from their stethoscopes, the only diagnostic tool available to the surgeons is a Soviet-era X-ray machine. Ultrasound equipment? No. CT scans? No. MRI? No. There are two thoracic surgeons for chest wounds, the most common kind of injury in bomb blasts, but the hospital lacks the equipment needed to perform actual surgery. Pleas for funds and tools have been ignored by an Iraqi health ministry that doctors say is underfunded, mismanaged and corrupt. "There are days when we don't even have enough sutures," Emad says with a hollow laugh.

The one commodity the Yarmouk Hospital has in abundance is doctors. A medical college next door supplies a steady stream of residents. Many of the best doctors fled Iraq before and after the war, but the demobilization of Saddam Hussein's army has left the country with a surplus of military surgeons, who are grateful for a hospital job that pays $350 a month. Their experience in battlefield medicine gives them the ability both to manage expectations and to improvise. "If a patient leaves the ER still breathing and not bleeding, then I would say we have done our job," says Qais Mohammed Ali, a thoracic and vascular surgeon. "We are not in the miracle business."

At the explosion site, the arrival of a police patrol finally signaled that it was safe to approach the three wounded men. Even then some people in the crowd were motivated not by sympathy but by greed: they tried to steal money from Abu Karam's pockets. "I was shocked when I saw some policemen taking money and new clothes from the damaged cars," says Hasan. But the crowd also included some selfless Iraqis who decided to take the injured men to Yarmouk rather than wait for ambulances to wind their way through the gridlocked traffic.

All three were still bleeding copiously on arrival at about 8:15 a.m. Salah was unconscious, Abu Karam barely awake. But although they could not have known it, they were very, very lucky. Theirs was the first (and, it turned out, only) bombing of the day in Baghdad, and they were the only seriously injured victims. This meant they would get the undivided attention of the ER team. "On other days we have had 20, 30, even 50 people here," says Emad, "and in the confusion, patients can die from simple things, like blood loss."

Another stroke of luck: the hospital had just received a fresh supply of blood, which was vital for Salah, who had lost so much that he needed a transfusion. By the time the rest of the TIME Baghdad staff was alerted and arrived at the hospital, the ER workers had done what they do best: stopped the blood loss and patched up the wounds. The ancient X-ray machine revealed that Abu Karam and Salah had many pieces of shrapnel lodged in their bodies, but there were no serious internal wounds.

In the absence of any other diagnostic equipment, however, the doctors had underestimated the seriousness of the injuries to Salah's left arm. "It looks superficial, and we have stopped the blood loss," said Emad. But he was unable to see that Salah had suffered two torn nerves, damaged tendons and, most dangerous of all, two torn arteries. The only blood flow to his arm was coming from collateral circulation, from minor blood vessels and capillaries in the skin. Left in that condition, the hand would have been irreparably damaged in two or three days.

The more immediate danger was the threat of secondary infections. The ER was the filthiest I have ever encountered. The floor was littered with medical debris--old bloodstained bandages, syringes, broken vials. The garbage bins had no plastic liners and were spattered with coagulated blood, gobs of spit and other fluids. Sweepers came through every hour with dirty mops and pails of brown disinfectant, but their halfhearted labor was quickly overwhelmed by the sheer numbers of patients and visitors. Nobody paid any attention to the NO SMOKING sign, not even the doctors and nurses. Broken windows allowed dust to enter, and swarms of flies buzzed around the patients; we used the X-ray films to swat them away. "All the rules of hygiene we learned have been broken here," said veteran nurse Hadi Abdel Karim as he paused for a cigarette break in a corner of the ER. "But we have no time and no money to spend on cleanliness." When I complained about the risk of secondary infections, Karim shrugged. "Infections?" he said. "First and foremost, the patients are at risk of dying from lack of the right medicines and equipment."

By early afternoon, the ER doctors had released our colleagues. Now our options were either to admit them into the surgical ward of the main hospital, where it would be five days before a surgeon would get around to stitching their wounds, or to move them to a private hospital for immediate stitching. Most Iraqis can't afford private hospitals, even though the rooms cost only $10 a day and specialists charge just $200 for serious surgery.

Our choice was to move both men to Harthiya Hospital, a private clinic. The floors are cleaned more often than at Yarmouk, the air-conditioning works, and there are fewer flies. Harthiya also has more modern equipment. Working in more salubrious conditions, Dr. Raed Abbas, a private surgeon, was able to diagnose the full extent of the damage to Salah's arm. But the best he could do was repair one artery. It didn't look likely that the arm and hand would regain full function, he said, but it was all he could do. "Your friend," he said, "has already been luckier than anybody else in his position. At this point, all we can do is pray to God."

As it turned out, we had a few other options. With the help of a medical-evacuation agency, TIME airlifted Salah to Amman, Jordan, where he underwent extensive reconstructive hand surgery. Abu Karam was released from the hospital to convalesce at his home in Baghdad. Because of the lack of medicines and equipment at the ER, both men are still at risk for secondary infections. But they are in the care of their families and are expected to recover. They were the fortunate ones. Waleed, the university student, suffered brain trauma from the shrapnel to his head and remains at the Yarmouk Hospital, another victim whose only mistake was to be on the wrong side of the road in the morning.

Back in the ER, the staff members have all but forgotten the patients they saw only hours earlier. Though there will be no more bombings this day, a steady stream of patients keeps Emad busy. "Sometimes we forget that not everybody who comes here has a bullet wound or shrapnel from a bomb blast," he says. "There are many ways for people to get hurt." But it isn't long before another war wound appears in the ER: a young man shot in the hip. "Here we go," Emad whispers, almost to himself, as he gets back to work. --With reporting by Asaad Saeed/Baghdad

With reporting by Asaad Saeed/Baghdad